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DEMONSTRATING YOUR CLINICAL
COMPETENCE IN DEPRESSION,
DEMENTIA, ALCOHOLISM,
PALLIATIVE CARE AND
OSTEOPOROSIS

Jane Higgs
Gill Wakley
Ruth Chambers
and
Clare Gerada

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
First published 2005 by Radcliffe Publishing

Published 2018 by CRC Press

Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2005 Jane Higgs, Gill Wakley, Ruth Chambers and Clare Gerada
CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

ISBN-13: 978-1-85775-744-6 (pbk)

This book contains information obtained from authentic and highly regarded sources. While all
reasonable efforts have been made to publish reliable data and information, neither the author[s] nor
the publisher can accept any legal responsibility or liability for any errors or omissions that may be
made. The publishers wish to make clear that any views or opinions expressed in this book by
individual editors, authors or contributors are personal to them and do not necessarily reflect the
views/opinions of the publishers. The information or guidance contained in this book is intended for
use by medical, scientific or health-care professionals and is provided strictly as a supplement to the
medical or other professional's own judgement, their knowledge of the patient's medical history,
relevant manufacturer's instructions and the appropriate best practice guidelines. Because of the
rapid advances in medical science, any information or advice on dosages, procedures or diagnoses
should be independently verified. The reader is strongly urged to consult the relevant national drug
formulary and the drug companies' and device or material manufacturers' printed instructions, and
their websites, before administering or utilizing any of the drugs, devices or materials mentioned in
this book. This book does not indicate whether a particular treatment is appropriate or suitable for a
particular individual. Ultimately it is the sole responsibility of the medical professional to make his or
her own professional judgements, so as to advise and treat patients appropriately. The authors and
publishers have also attempted to trace the copyright holders of all material reproduced in this
publication and apologize to copyright holders if permission to publish in this form has not been
obtained. If any copyright material has not been acknowledged please write and let us know so we
may rectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying, microfilming, and recording, or in any information
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Visit the Taylor &: Francis Web site at

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British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

Typeset by Advance Typesetting Ltd, Oxford

 Contents
Preface v

About the authors viii

Chapter 1 Making the link: personal development plans,

post-registration education and practice (PREP) and portfolios 1
The process of lifelong learning 1
Your personal development plan 2
Using portfolios for appraisal/individual performance review,
KSF and PREP 3
Demonstrating the standards of your practice 5
Preparing your portfolio 11

Chapter 2 Practical ways to identify your learning and service

needs as part of your portfolio 15
Setting standards to show that you are competent 15
Identify your learning needs - how you can find out
if you need to be better at doing your job 16
Identify your service needs - how you can find out if
there are gaps in services or how you deliver care 25
Set priorities: how you match what’s needed with what’s possible 33

Chapter 3 Demonstrating common components of good

quality healthcare 35
Consent 35
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery: consent 37
Confidentiality 40
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery:confidentiality 42
Learning from complaints 45
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery: complaints 46

Chapter 4 Depression 51
What issues you should cover 52
Treatment of depressive disorders 56
Quality and outcomes framework indicators inmental health 63
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery 65
iv Contents

Chapter 5 Dementia 77
Prevalence of dementia 77
What issues you should cover 78
Treatment of dementia 86
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery 89

Chapter 6 Alcohol problems 99

What issues you should cover 99
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery 105

Chapter 7 Palliative care 117

What issues you should cover 117
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery 129

Chapter 8 Osteoporosis 139

What issues you should cover 139
Collecting data to demonstrate your learning, competence,
performance and standards of service delivery 143

And finally 153

Index 155
 Preface
The Nursing and Midwifery Council requires nurses to maintain a professional
portfolio.1 The onus is on individual nurses to decide how they will collect and keep
the information that will show that they are clinically competent and that they have
taken on board the concept of lifelong learning. Nurses themselves need to decide the
nature of the information they collect and retain, in order to have their everyday roles
and responsibilities most accurately represented. The National Prescribing Centre2
along with the Department of Health and professional organisations also requires
nurse prescribers to maintain their competency in prescribing.
This book is one of a series that will guide you as a nurse though the process, giving
you examples and ideas as to how to document your learning, competence, performance
or standards of service delivery. Chapter 1 explains the link between your personal
development plans, professional portfolio and individual performance reviews. Learn­
ing and service improvements that are integral to your personal development plan are
central to the evidence you include in your portfolio. The stages of the evidence cycle
that we suggest are reproduced from the Good Appraisal Toolkit3 emphasising the
importance of documenting evidence from your learning and practice in your professional
portfolio.

Stage 1 is about setting targets or aspirations for good practice. Stage 2 encourages
you, as a nurse, to set standards for the outcomes of what you plan to learn more
about, or outcomes relating to you providing a good service in your practice.
vi Preface

Chapter 2 describes a variety of methods to help you to address Stage 3 of the cycle of
evidence, to find out what it is you need to learn about or what gaps there are in the
way you deliver care as an individual or as a team. This chapter includes a wide variety
of methods nurses might use in their everyday work to identify and document these
needs. One of the main drivers for striving to improve practice is to benefit individual
patients. So it makes sense that we have emphasised the importance of obtaining
feedback from patients in this chapter in relation to identifying your learning and
service development needs.
Best practice in addressing the giving of informed consent by patients, maintaining
confidentiality of patient information and organising responsive complaints processes
are all common components of good quality healthcare. Chapter 3 covers these
aspects in depth and provides the first example of cycles of evidence for you to consider
adopting or adapting for your own circumstances.
The rest of the book consists of five clinically based chapters that mainly span key
topics in meeting the General Medical Services (GMS) quality framework. Attention to
these areas can ensure that achieving quality points for the practice also achieves
positive clinical outcomes for the patients. Some of the quality indicators are generic to
various clinical areas such as smoking status, smoking cessation advice and influenza
immunisation, and they obviously overlap. Others such as good record keeping, a
consistent approach to maintaining disease registers, medicines management and
education/appraisal of staff should underpin all the clinical areas. As we cover the five
clinical topics in this book in Chapters 4 to 8, we point out what quality points are
available in that clinical area. Other books in the series also include clinical topics
within the scope of the GMS quality framework - so it will be useful for you to read
them too (e.g. coronary heart disease, stroke and epilepsy are included in: Higgs J,
Wakley G, Chambers R and Ellis S (20 0 4 ) Demonstrating Your Clinical Competence in
Cardiovascular and Neurological Conditions. Radcliffe Publishing, Oxford).
The first part of each clinical chapter covers key issues that are likely to crop up in
typical clinical scenarios. The second part of each chapter gives examples of cycles of
evidence in a similar format to those in Chapter 3.
Overall, you will probably want to choose three or four cycles of evidence each year.
You might choose one or two from Chapter 3 and the rest from clinical areas such as
those covered by Chapters 4 to 8. You might like this way of learning and service
development so much that you build up a bigger bank of evidence, taking one cycle
from each chapter in the same year. Whatever your approach, you will want to keep
your cycles of evidence as short and simple as possible, so that the documentation itself
is a by-product of the learning and action plans you undertake to improve the service
you provide, and does not dominate your time and effort at work.
Other books in the series are based on the same format of the five stages in the cycle
of evidence. Book 1 helps nurses and other health professionals to demonstrate that
they are competent teachers or trainers, and Books 2, 3 and 4 set out key information
and examples of evidence for a wide variety of clinical areas for nurses and other
healthcare practitioners.
This approach and style of learning will take a bit of getting used to for many nurses.
Until recently, most nurses did not reflect on what they learnt or whether they applied
it in practice. They did not protect time for learning and reflection among their
Preface vii

everyday responsibilities, or target their time and effort on priority topics. Times are
changing, and with the introduction of personal development plans and individual
performance reviews, nurses are realising that they must take a more professional
approach to learning and document their standards of competence, performance and
service delivery. This book helps them to do just that.
Please note that resources to support this book are provided at http;//
health.mattersonline.net.

References
1 www.nmc-uk.org (accessed 25 April 2 0 0 5 )
2 www.npc.co.uk (accessed 25 April 2 0 0 5 )
3 Chambers R, Tavabie A, Mohanna K and Wakley G (2 0 0 4 ) The Good Appraised Toolkit for
Primary Care. Radcliffe Publishing, Oxford.
 About the authors
Jane Higgs has worked in primary care predominantly in district nursing and in
practice nursing. She trained as a community practice educator (CPE) and is currently
clinical practice development nurse for district nurses, health visitors and practice
nurses, supporting health professionals to improve their clinical practice through
benchmarking, clinical supervision and evidence-based guidelines and by providing
advice and training support. She has been involved in developing clinical practice
benchmarks and core competency frameworks regionally. She has developed various
educational initiatives and training activities and is also the nurse prescribing lead for
a primary care trust in the northwest of England.

Gill Wakley started in general practice but transferred to community medicine

shortly afterwards and then into public health. A desire for increased contact with
patients caused a move back into general practice. She has been heavily involved in
learning and teaching throughout her career. She was in a training general practice,
became an instructing doctor and a regional assessor in family planning, and was
until recently a senior clinical lecturer with the Primary Care Department at Keele
University. Like Ruth, she has run all types of educational initiatives and activities. A
visiting professor at Staffordshire University, she now works as a freelance GP, writer
and lecturer.

Ruth Chambers has been a general practitioner (GP) for more than 2 0 years and is
currently the head of the Stoke-on-Trent Teaching Primary Care Trust programme
and professor of primary care development at Staffordshire University. Ruth has worked
with the Royal College of General Practitioners (RCGP) to enable GPs to gather
evidence about their learning and standards of practice while striving to be excellent
GPs. Ruth has co-authored a series of books with Gill, designed to help readers draw up
their own personal development plan or workplace learning plans around key clinical
topics.

Clare Gerada has been a GP in a South London practice for 14 years and previously
trained as a psychiatrist at the Maudsley Hospital. She has a special interest in drug
misuse and leads the RCGP’s drug misuse training programme. She has worked in the
Department of Health in various guises for a number of years and is currently Director
of Primary Care for the Clinical Governance Support Team. She has published widely
on a number of topics related to drug and alcohol problems, primary care and clinical
governance. She led the RCGP development of the frameworks for general prac­
titioners with special interests.
1

Making the link: personal

development plans,
post-registration education and
practice (PREP) and portfolios

The process of lifelong learning

The professional regulatory body for nursing, the Nursing and Midwifery Council
(NMC), has stated within the Professional Code of Conduct (2 0 0 2 ) that all registered
nurses must maintain their professional knowledge and competence.1 The code states
‘you should take part regularly in learning activities that develop your competence
and performance’. This means that learning should be lifelong and encompass
continuing professional development (CPD). The formal requirements for nurses to
re-register state that nurses must meet the post-registration education and practice
standards (PREP). This includes completion of 750 hours in practice during the five
years prior to renewal of registration, together with evidence that the nurse has met
the professional standards for CPD. This standard comprises a minimum of five days’
(or 35 hours’) learning activity relevant to the nurse’s clinical practice in the three
years prior to renewal of professional registration.2 This requirement is seen as
minimal by many nurses who would profess to undertake much more CPD than
this in order to keep themselves abreast of current changes in practice. However,
many nurses pay little attention to the recording of their CPD activity. This chapter
will help you to identify a suitable format for recording learning that occurs in both
clinical and educational settings.
Learning involves many steps. It includes the acquisition of information, its retention,
the ability to retrieve the information when needed and how to use that information
for best practice. Demonstrating your learning involves being able to show the steps
you have taken. CPD takes time. It makes sense to utilise the time spent by overlapping
learning undertaken to meet your personal and professional needs with that required
for the performance of your role in the health service.
All nurses are required to maintain a personal professional portfolio of their
learning activity. This is essential to maintain registration with the NMC.2 Many
nurses have drawn up a personal development plan (PDP) that is agreed with their line
manager. Some nurses have constructed their PDP in a systematic way and identified
2 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

the priorities within it, or gathered evidence to demonstrate that what they learnt
about was subsequently applied in practice. The NMC does not have a uniform
approach to the style of a PDP. Some nurse tutors or managers are content to see that a
plan has been drawn up, while others encourage the nurse to develop a systematic
approach to identifying and addressing their learning and service needs, in order of
importance or urgency.
The new emphasis on lifelong learning for nurses has given the PDP a higher profile.
Nurse educationalists view a PDP as a tool to encourage nurses to plan their own
learning activities. Managers may view it as a tool that allows quality assurance of the
nurse’s performance. Nurses, striving to improve the quality of the care that they
deliver to patients, may want to use a PDP to guide them on their way, perhaps
towards post-registration awards or towards gaining promotion opportunities.

Your personal development plan

Your PDP will be an integral part of your annual appraisal (sometimes referred to as
an individual performance review) and your portfolio that is required by the NMC to
demonstrate your fitness to practise as a nurse.
Your initial plan should:
• identify your gaps or weaknesses in knowledge, skills or attitudes
• specify topics for learning as a result of changes: in your role, responsibilities, the
organisation in which you work
• link into the learning needs of others in your workplace or team of colleagues
• tie in with the service development priorities of your practice, the primary care
organisation (PCO), hospital trust or the NHS as a whole
• describe how you identified your learning needs
• set your learning needs and associated goals in order of importance and urgency
• justify your selection of learning goals
• describe how you will achieve your goals and over what time period
• describe how you will evaluate learning outcomes.3
Each year you will continue to revise your personal development plan to support the
development review process of The NHS Knowledge and Skills Framework (NHS KSF).4
It should demonstrate how you carried out your learning and evaluation plans, show
that you have learnt what you set out to do (or why it was modified) and how you
applied your new learning in practice. In addition, you will find that you have new
priorities and fresh learning needs as circumstances change.
The main task is to capture what you have learnt, in a way that suits you. Then you
can look back at what you have done and:
• reflect on it later, to decide to learn more, or to make changes as a result, and
identify further needs
• demonstrate to others that you are fit to practise or work through:
- what you have done
- what you have learnt
Making the link: personal development plans, PREP and portfolios 3

- what changes you have made as a result

- the standards of work you have achieved and are maintaining
- how you monitor your performance at work
• use it to show how your personal learning fits in with the requirements of your
practice or the NHS, and other people’s personal and professional development
plans.
Incorporate all the evidence of your learning into your personal professional profile
(PPP). Evidence from this document will be needed if you are asked to take part in the
NMC audit, which is designed to ensure that all nurses are complying with the PREP
standard. It is up to you how you keep this record of your learning. Examples are:
• an ongoing learning journal in which you draw up and describe your plan, record
how you determined your needs and prioritised them, report why you attended
particular educational meetings or courses and what you got out of them as well as
the continuing cycle of review, making changes and evaluating them
• an A4 file with lots of plastic sleeves into which you build up a systematic record of
your educational activities in line with your plan
• a box: chuck in everything to do with your learning plan as you do it and sort it out
into a sensible order every few months with a good review once a year.

Using portfolios for appraisal/individual

performance review, KSF and PREP
Appraisal is widely accepted in the NHS as a formative process that should be concerned
with the professional development and personal fulfilment of the individual, leading to
an improvement in their performance at work. It is a formal structured opportunity
whereby the person being appraised has the opportunity to reflect on their work and to
consider how their effectiveness might be improved. This positive interpretation of the
appraisal process supports the delivery of high-quality patient care and drive to improve
clinical standards. Appraisal has been in place in industry, commerce and public
sectors for decades. In the NHS, nurses and other health professionals, managers and
administrative staff are now all expected to undergo annual appraisals.
Nurses working in the health service should receive an appraisal or individual
performance review at least once a year. This appraisal should include two main
functions. Firstly there should be an assessment of fitness to practise in the current
role, and secondly there should be a review of the CPD that has taken place and that is
needed for the future. This should focus on the needs of the individual together with
the needs of the organisation for which the nurse works.
Details of how annual appraisals are structured will vary from one organisation to
another, but the educational principles remain the same. The aims are to give nurses
an opportunity to discuss and receive regular feedback on their previous and con­
tinuing performance and identify education and development needs.
With the introduction of the Agenda for Change Knowledge and Skills Framework
(KSF),4 nurses may find their appraisal incorporated into the KSF development review
4 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

process, which has been designed to identify the knowledge and skills that individuals
need to apply in their post; to help guide their development; to provide a fair and
objective framework to base review and development of all staff; and to provide the
basis of pay progression in the service. The main purpose of the development review is
to look at the way an individual member of staff is developing in relation to the duties
and responsibilities of their post, their application of knowledge and skills and the
consequent development needs. Your portfolio will be required as evidence for this
development review.
In 19 9 5 , the United Kingdom Central Council (UKCC) introduced the need to
demonstrate that you have undertaken meaningful learning activities, directly related
to your nursing role. As the superseding professional body, the NMC has maintained
this PREP requirement. When you apply to renew your registration as a nurse every
three years, you are required to sign a Notification of Practice form that includes a
declaration that you have met the PREP requirements. This means that your employer
may be at liberty to ask to see your personal professional profile that will show the
learning activities undertaken and how these have influenced your work. The term
portfolio and profile tend to be used synonymously in nursing. A helpful view on
distinguishing between the two terms has been given by Rosslyn Brown who views the
portfolio as encompassing the development of the individual as a whole (including
both personal and professional perspectives), whereas the profile provides a more
focused approach to the professional development and may be produced for a more
clearly defined audience.5
The English National Board (ENB) stipulated that portfolios should be incorporated
into pre-registration nursing programmes in 199 7.6 This demonstrates that portfolios
are designated as part of the culture of nursing. They should not be viewed simply as a
tool for assessing outcomes of courses, but as meaningful documents that provide firm
evidence of an individual’s journey and progression within nursing. You do not need
to set out your portfolio in any specific format. In fact, one of the benefits of using a
portfolio is that it allows you to be creative and to produce evidence about your
practice in a way that reflects your individual style. However, there are certain
elements that should be included. Quinn suggests six main areas:7
• factual information e.g. qualifications, job description, etc
• self-evaluation of professional performance
• action plans/PDP
• documentation of any formal learning undertaken, such as courses attended, etc
• documentation of informal learning, such as reading journal articles that have
altered your practice by providing a firm evidence base to follow
• documentation of hours worked between registration periods. This may be par­
ticularly important if you do not have a regular contract of employment.7

A portfolio will provide evidence that you have complied with the NMC Professional
Code of Conduct (20 0 2 ). This clearly states that your professional knowledge must be
maintained in the ways given in Box 1.1.
Making the link: personal development plans, PREP and portfolios 5

Box 1.1: Nursing and Midwifery Council requirements for maintaining

professional knowledge
• You must keep your knowledge and skills up to date throughout your
working life. In particular, you should take part regularly in learning activities
that develop your confidence and performance.
• To practise competently, you must possess the knowledge, skills and abilities
required for lawful, safe and effective practice without direct supervision.
You must acknowledge the limits of your professional competence and only
undertake practice and accept responsibilities for those activities in which
you are competent.
• If an aspect of practice is beyond your level of competence or outside your
area of registration, you must obtain help and supervision from a competent
practitioner until you and your employer consider that you have acquired
the requisite knowledge and skill.
• You have a duty to facilitate students of nursing and midwifery and others to
develop their competence.
• You have a responsibility to deliver care based on current evidence, best
practice and, where applicable, validated research when it is available.
Reproduced from: Nursing and Midwifery Council (2002) Code of Professional
Conduct. Nursing and Midwifery Council, London1

Lifelong learning is a concept that is advocated by the NMC in order to develop

professional knowledge and competence in order to improve patient care.8 Lifelong
learning can be structured to ensure that learning is meaningful and relevant to your
current role. The best way to do this is to incorporate a PDP as a central part of your
portfolio. It provides a framework to highlight your learning needs and demonstrates
self-awareness and organisation of prioritised learning. Ideally, the PDP should arise
from your individual performance review, as this will have utilised both subjective and
objective assessments to highlight your developmental needs.

Demonstrating the standards of your practice

The NMC sets out standards that must be met as part of the duties and responsibilities
of nurses in the Professional Code of Conduct.1 These clauses within the code have
been drawn up to create expectations for the public relating to the behaviour that they
can expect from nurses, and to create a uniform standard of behaviour with which all
nurses must comply. A good portfolio should reflect these standards of care wherever
possible. For example, confidential information should be protected, so that if your
portfolio includes reflective writing there should be no way of identifying specific
patients within this. The clauses within the Code of Conduct are shared values from all
the UK healthcare regulatory bodies. Box 1.2 lists the requirements within the code.
6 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

Box 1.2: Clauses to consider when creating a portfolio which relates to

clinical care
In caring for patients and clients, you must:
• respect the patient or client as an individual
• obtain consent before you give any treatment or care
• protect confidential information
• co-operate with others in the team
• maintain your professional knowledge and competence
• be trustworthy
• act to identify and minimise risk to patients and clients.
Reproduced from: Nursing and Midwifery Council (2002) Code of Professional
Conduct Nursing and Midwifery Council, London1

In order to demonstrate that your clinical practice upholds these professional stand­
ards you will need to include evidence within your portfolio. The evidence cycle shown
in Figure 1.1 provides a comprehensive model for demonstrating your standards
of practice and how you seek to improve them. The stages of the evidence cycle are
common to all the various areas of expertise considered in this book and will be
followed in each chapter.

Figure 1.1: Stages of the evidence cycle.

Making the link: personal development plans, PREP and portfolios 7

Although the five stages are shown in sequence here, in practice you would expect to
move backwards and forwards from stage to stage, because of new information or a
modification of your earlier ideas. New information might accrue when research is
published which affects your clinical behaviour or standards, or a critical incident or
patient complaint might occur which causes you and others to think anew about your
standards or the way that services are delivered. The arrows in Figure 1.1 show that
you might reset your target or aspirations for good practice, having undertaken
exercises to identify what you need to learn or determine whether there are gaps in
service delivery.
We suggest that you demonstrate your competence in focused areas of your day-to-
day work by completing several cycles of evidence drawn from a variety of clinical or
other areas each year.
As you start to collate information about this five-stage cycle, discuss any problems
about the standards of care or services you are looking at, with colleagues, experts in
this area, tutors, etc. You want to develop a wide range and depth of evidence so that
you can show that you are competent in your day-to-day general work as well as for
any special areas of expertise.
Professional competence is the first area of concern to employers and the public.
You should be able to demonstrate that you can maintain a satisfactory standard of
clinical care most of the time in your everyday work. Some of the time you will be
brilliant, of course! Celebrate those moments. On other occasions, you or others around
you will be critical of your performance and feel that you could have done much better.
Reflect on those episodes to learn from them.

Stage 1: Select your aspirations for good practice

By adopting or adapting descriptions of what an ‘excellent’ nurse should be aiming for,
you are defining the standards of practice for which you, as an individual nurse, should
be aiming. You may find it easier to define your standards initially in terms of what
standards are unacceptable to you. Your standards may be influenced by role models
whom you have identified as being particularly skilled in a certain area of practice. It
may be helpful to note down these particular qualities to which you aspire. However, it
is also useful to note that some practitioners define ‘excellence’ as being consistently
good.9 Indeed you may recognise that this is much harder to achieve (and demon­
strate) than sporadic bursts of excellence.
This consistency is a critical factor in considering competence and performance too
(see page 15). The documents that you collect in your evidence cycles must reflect
consistency over time and in different circumstances, for example with various types of
patients or your practice at different times of day. This will show that you have not
only performed well on one occasion or for one type of baseline assessment, but also
sustained your performance over time and under different conditions.
8 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

Stage 2: Set the standards for your outcomes - for being

competent and providing a good service
Outcomes might include:
• the way that learning is applied
• a learnt skill
• a protocol
• a strategy that is implemented
• meeting recommended standards.

The level at which you should be performing depends on your particular field of
expertise. Generalist nurses are good at seeing the wider picture, while specialists tend
to be expert in a narrow area, so that the level of competence expected for a clinical
area will vary depending on the nurse’s role and responsibilities. You would not, for
example, expect nurse specialists in women’s health to be competent at managing
patients with cardiac failure (although some of them may be), but you would expect
practice nurses to be able to manage a wide variety of conditions, but with limited
expertise in certain areas. You would expect both the specialist nurse and the generalist
nurse to recognise their ‘scope of professional practice’10 and to refer to someone with
more expertise when necessary.
Other standards include using resources effectively and the record keeping that is
an essential tool in clinical care. As a health professional, you need to be accessible and
available so that you can provide your services, and make suitable arrangements for
handing over care to others. You could incorporate into your standards or outcomes
those components specified by universities at a national level as part of their Masters
Frameworks for their postgraduate awards. The Masters Frameworks consist of eight
components that shape the individual postgraduate award programme outcomes and
the learning outcomes of the individual modules for the postgraduate awards. The
eight components are shown in Box 1.3. You could set out your CPD work in the
portfolio you are assembling for re-registration and your annual appraisals in this
format. This would help you to document your professional development to date in
a form that can be readily ‘accredited for prior experiential learning’ (APEL) by
universities (contact your local universities if you want more information about this
process). You might then be given credits for learning against an intended postgraduate
award. It would save you from duplicating work as well as speeding your progress
through the award.

Box 1.3: The eight components of the Masters Frameworks for postgraduate
awards
1 Analysis
2 Problem solving
3 Knowledge and understanding
4 Reflection
5 Communication
Making the link: personal development plans, PREP and portfolios 9

6 Learning
7 Application
8 Enquiry

If you have information or data about your work showing that it was substandard or
that you were not competent, you might choose to exclude that from your portfolio.
However, you will be able to show that you have learnt more by reviewing mistakes
or negative episodes. It is better to include everything of relevance, then go on to
demonstrate how you addressed the gaps in your performance and made sustained
improvements. You will need to protect the confidentiality of patients and colleagues
as necessary when you collect data. The NMC will be seeing the contents of your re­
registration portfolio if your submission is one of those sampled. You will probably also
submit or share the documentation for job interviews and for your appraisal and
maybe use it for reviews within clinical supervision sessions.

Stage 3: Identify your learning and service needs in your

work or trust and rank them in order of priority3
The type and depth of documentation you need to gather will encompass:
• the context in which you work
• your knowledge and skills in relation to any particular role or responsibility of your
current post.
The extent of expertise you should possess will depend on your level of responsibility
for a particular function or task. You may be personally responsible for that function or
task, or you may contribute or delegate responsibility for it. Your learning needs
should take into account your aspirations for the future too - personal or career
development for you, or improvements in the way you deliver care in your practice.
Look at Chapter 2 for more ideas on how you will identify your learning or service
development needs.
Group and summarise your service development needs from the exercises you have
carried out. Grade them according to the priority you set. You may put one at a higher
priority because it fits in with service development needs established in the business
plan of the trust or practice, or put another lower because it does not fit in with other
activities that your organisation has in their current development plan for the next
12 months. If you have identified a service development need by various methods of
assessment, or with several different patient groups or clinical conditions, then it will
have a higher priority than something only identified once. Notify the service develop­
ment needs you have identified to those responsible for agreeing and implementing the
development plans of the trust and/or practice.
Look back at your aspirations and standards set out in Stages 1 and 2. Match your
learning or service development needs with one or more of these standards, or others
that you have set yourself.
10 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

Stage 4: Make and carry out a learning and action plan with
a timetable for your personal and service development
If you have not identified any learning needs for yourself or the service as a whole, you
should omit Stage 4 and tidy up the presentation of your evidence for inclusion in your
portfolio as at the end of Stage 5.
Think about whether:
• you have defined your learning objectives - what you need to learn to be able to
attain the standards and outcomes you have described in Stage 2
• you can justify spending time and effort on the topics you prioritised in Stage 3. Is
the topic important enough to your work, the NHS as a whole or patient safety?
Does the clinical or non-clinical event occur sufficiently often to warrant the time
spent?
• the time and resources for learning about that topic or making the associated
changes to service delivery are available. Check that you are not trying to do too
much too quickly, or you will become discouraged
• learning about that topic will make a difference to the care you or others can
provide for patients
• and how one topic fits in with other topics you have identified to learn more about.
Have you achieved a good balance across your areas of work or between your
personal aspirations and the basic requirements of the service?
Decide on what method of learning is most appropriate for your task or role or the
standards you are expecting to attain or sustain. You may have already identified your
preferred learning style - but read up on this elsewhere if you are unsure.
Describe how you will carry out your learning tasks and what you will do by a
specified time. State how your learning will be applied and how and when it will be
evaluated. Build in some staging posts so that you do not suddenly get to the end of
12 months and discover that you have only done half of your plan.
Your action plan should also include your role in remedying any gaps in service
delivery that you identified in Stage 3 that are within the remit of your responsibility.

Stage 5: Document your learning, competence, performance

and standards of service delivery
You might choose to document that you have attained your defined outcomes by
repeating the learning needs assessment that you started with. You could record your
increased confidence and competence in dealing with situations that you previously
avoided or performed inadequately.
You might incorporate your assessment of what has been gained in a study of
another area that overlaps.
Making the link: personal development plans, PREP and portfolios 11

Preparing your portfolio

Use your portfolio of evidence of what you have learnt and your standards of practice to:
• identify significant experiences to serve as important sources of learning
• reflect on the learning that arose from those experiences
• demonstrate learning in practice
• analyse and identify further learning needs and ways in which these needs can be
met.
Your documentation might include all sorts of things, not just formal audits -
although they make a good start. It might include reports of educational activities
attended, statements of your roles and responsibilities, copies of publications you have
read and critically appraised, and reports of your work. You could incorporate obser­
vations by others, evaluations of you observing other colleagues and how their practice
differs from yours, descriptions of self-improvements, a video of typical activity, materials
that demonstrate your skills to others, products of your input or learning - a new
protocol for example. Box 1.4 gives a list of material you might include in your
portfolio.

Box 1.4: Possible contents of a portfolio

• Workload logs
• Case descriptions
• Videos
• Audiotapes
• Patient satisfaction surveys
• Research surveys
• Report of change or innovation
• Commentaries on published literature or books
• Records of critical incidents and learning points
• Notes from formal teaching sessions with reference to clinical work or other
evidence

When you are preparing to submit your portfolio for a discussion with your manager
(for example, at an appraisal) or for an assessment (for example, for a university post­
registration award), write a self-assessment of your previous action plan. You might
integrate your self-assessment into your PDP to show what you have achieved and
what gaps you have still to address. Decide where you are now and where you want to
be in one, three or five years’ time.
Make sure all references are included and the documentation in your portfolio is as
accurate and complete as possible. Organise how you have shown your learning steps
and your standards of practice so that it is indexed and cross-referenced to the relevant
sections of the paperwork. Discuss the contents of your portfolio with a colleague or a
mentor to gain other people’s perspectives of your work and look for blind spots.
12 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

Reflective writing within the portfolio

Reflective writing has been endorsed by the NMC as an excellent way of analysing
practice and learning from your everyday experiences.2 Reflective writing can also be
useful to analyse what you have learnt from attending formal learning sessions and
considering how any newly acquired knowledge may be applied to practice. In order to
provide a comprehensive structure to reflective writing it is recommended that a
model of reflection is adopted. This will help you to learn from your experience in a
more logical and holistic manner. There are numerous models of reflection and it is
best to choose a model which appears straightforward to you and seems to fit with
your own style of thinking.11-13
Reflective writing introduces a personal element into your portfolio. It enables
anyone reading the portfolio to gain insight into your practice. It is useful in creating a
picture, which gives access to the artistry of nursing, and may demonstrate the
therapeutic use of self in patient interactions.

Include evidence of your competence as a practitioner with a

special interest
You may have a particular expertise or special interest in a clinical field or non-clinical
area such as management, teaching or research. It may be that you have a lead role or
responsibility in your practice for chronic disease management of clinical conditions
such as diabetes, asthma, mental health or coronary heart disease or as a community
matron with responsibility for case management of patients with long-term conditions
and high-intensity needs.14 You may be employed by a PCO or hospital trust to:
• lead in the development of services
• deliver a procedure-based service
• deliver an opinion-based service.

The role of practitioner with special interest (PwSI) is being promoted as a role to help
to bridge the gap between hospital and the community.14 Realising the potential of
nurses and allied health professionals working in specialist roles will facilitate the
redesign of primary care services. It may be particularly important for you, as a
specialist, to be able to demonstrate your clinical expertise if you are seeking to gain a
position as a PwSI. There is little consistency in the extent of training or qualifications
at present within or across the various PwSI specialty areas.14 Whatever your role,
responsibility or expertise, your portfolio should include examples of evidence that
show that you are competent, and that you have a consistently good performance in
your specialty area. You may have parallel appraisals that you can include from your
employer - for example, the university if you have a research or teaching post, or a
hospital consultant if he or she supervises you in the clinical specialty.
When you gather evidence of your performance at work, try to document as many
aspects of your work at one time as you can. When you are identifying what you need
to learn, or gaps in service delivery, make sure that you involve patients and show how
you interact with the team. This gives you evidence about ‘relationships with patients’
Making the link: personal development plans, PREP and portfolios 13

and ‘working with colleagues’ as well as the clinical area that you are focusing on or
auditing.

References
1 Nursing and Midwifery Council (2 0 0 2 ) Code o f Professional Conduct. Nursing and Mid­
wifery Council, London.
2 Nursing and Midwifery Council (2 0 0 1 ) The PREP Handbook. Nursing and Midwifery
Council, London.
3 Wakley G, Chambers R and Field S (2 0 0 0 ) Continuing Professional Development in Primary
Care. Radcliffe Medical Press, Oxford.
4 Department of Health (2 0 0 4 ) The NHS Knowledge and Skills Framework (NHS KSF) and the
Development Review Process. Department of Health, London.
5 Brown R (1 9 9 5 ) Portfolio Development and Profiling for Nurses (2e). Quay Publishing,
Wiltshire.
6 English National Board for Nursing, Midwifery and Health Visiting (1 9 9 7 ) Standards for
Approval of Higher Education Institutions and Programmes. English National Board for
Nursing, Midwifery and Health Visiting, London.
7 Quinn F (2 0 0 0 ) Principles and Practice o f Nurse Education (4e). Stanley Thornes Ltd,
London.
8 Nursing and Midwifery Council (2 0 0 2 ) Supporting Nurses and Midwives through Lifelong
Learning. Nursing and Midwifery Council, London.
9 Royal College of General Practitioners/General Practitioners Committee (2 0 0 2 ) Good
Medical Practice for General Practitioners. Royal College of General Practitioners, London.
10 Nursing and Midwifery Council (1 9 9 2 ) Scope o f Professional Practice. Nursing and Mid­
wifery Council, London.
11 Gibbs G (1 9 9 8 ) Learning by Doing: a guide to teaching and learning methods. Further
Education Unit, Oxford Polytechnic, London.
12 Johns C (199 6) Using a reflective model of nursing and guided reflection. Nursing Standard.
11(2): 3 4 -8 .
13 Schon D (1 9 8 3 ) The Reflective Practitioner: how professionals think in action. Basic Books,
New York.
14 Department of Health (2 0 0 3 ) Practitioners with Special Interests in Primary Care: imple­
menting a scheme for nurses with special interests in primary care. Department of Health,
London. www.dh.gov.uk/assetRoot/04/06/92/07/04069207.pdf (accessed 25 April
2005)
2
Practical w ays to identify
your learning and service needs
as part of your portfolio

Setting standards to show that you are

competent
The Nursing and Midwifery Council (NMC) stresses the importance of lifelong learn­
ing. The Council recognises that healthcare is an area of constant change which
necessitates a dynamic approach to learning. In order to develop and maintain your
competence you are required to ‘demonstrate responsibility for your own learning
through the development of a portfolio ... and to be able to recognise when further
learning and development may be required’.1
You could make a good start by describing your current roles and responsibilities.
This will help you to define what your competence should be now, or what com­
petence you are hoping to attain (for instance as a specialist nurse). Once you have
your definition, you can recognise whether you have, or lack in some part, the
necessary competence. If there are no accepted descriptions of competence in the area
you are focusing on, then you will have to start from scratch. You might compile your
description using items from national guidelines such as in the National Service
Frameworks or health strategies or Agenda for Change.2 The Department of Health
has produced ideas relating to the role of nurses with special interests that you may
find useful to adopt.3
Your definition of competence is likely to relate to your ability to undertake a task or
role to a required standard. However, you will need to describe the standards expected
in the range of tasks and roles you undertake, and reference the source of standard
setting. If professionals, or their organisations, are the only people involved in setting
those standards, consider whether you should amend or extend the standards, tasks or
roles by considering other perspectives, such as those of patients or your employing
trust or practice.
There is a difference between being competent, and performing in a consistently
competent manner. You need to be motivated to perform consistently well and enabled to
do so with efficient systems and sufficient resources. You will require sufficient numbers of
other competent healthcare professionals and available infrastructure such as diagnostic
16 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

and treatment resources. It is partially your responsibility to alert managers to the

resources needed to undertake your role effectively.
Choose methods in Stage 3 (see Chapter 1) to demonstrate your standards of
performance and identify any learning needs that span different topic areas, to reduce
duplication and maximise the usefulness of your learning. Collecting evidence of more
than one aspect of your competence or performance cuts down the overall amount of
work underpinning your PDP or included in your appraisal portfolio.
Use several methods to identify your learning needs and/or gaps in your service
development or delivery, so that you validate the findings of one method by another.
No one method will give you reliable information about the gaps in your knowledge,
skills or attitudes or everyday service. Does what you think about your performance
match with what others in the team or patients think of how you practise in your
everyday work? It is particularly difficult to determine what it is you ‘don’t know you
don’t know’ by yourself, yet it is vital that you identify and rectify those gaps. Other
people may be able to tell you what you need to learn quite readily. Colleagues from
different disciplines could usefully comment on any shortfalls in how your work
interfaces with theirs.
Patients or people who don’t use your services could tell you whether the way you
work or provide services is off-putting or inappropriate. There may be data about your
performance or your approach that could point out those gaps in your knowledge or
skills of which you were previously unaware.
Determine what it is that you ‘don’t know you don’t know’ by:
• asking patients, users and non-users of your service
• comparing your performance against best practice or that of peers
• comparing your performance against objectives in business plans or national
directives
• asking colleagues from different disciplines about shortfalls in how your work
interfaces with theirs.

Identify your learning needs - how you can

find out if you need to be better at doing
your job
You may decide to use a few selected methods to gather baseline evidence of your
performance, focused on your specific area of expertise. Once you have identified your
learning needs you will be able to create a flexible way to progress that takes account of
your needs and circumstances. In order to establish your current position with a
degree of objectivity you might use several of the methods described in this chapter
such as:
• constructive feedback from peers or patients
• 3 60° feedback
Practical ways to identify your learning and service needs 17

• self-assessment, or review by others, using a rating scale to assess your skills and
attitudes
• comparison with local or national protocols and guidelines for checking how well
procedures are followed
• evaluative audit
• significant event audit
• eliciting patient views through methods such as satisfaction surveys
• a SWOT (strengths, weaknesses, opportunities and threats) or SCOT (strengths,
challenges, opportunities and threats) analysis
• reading and reflecting
• educational review.
Several of these methods will also be useful for identifying any service development
needs — you can look at the gaps identified from both the personal and service
perspectives at the same time using the same method.

Seek feedback
Find colleagues who will give you constructive feedback about your performance and
practice. Don’t be afraid to ask for comments on your style or work - just think how
upsetting it would be if you were consistently doing something that irritated col­
leagues, but continued because nobody bothered to tell you the effect it was having.
The golden rule for giving constructive feedback is to give positive praise of things that
have been well done first. Sometimes colleagues launch straight in to criticise faults
when asked for their views. The Pendleton model of the giving of feedback is widely
used in the health setting (see Box 2 .1 ):4

Box 2.1: The Pendleton model of giving feedback

1 The ‘learner’ goes first and performs the activity.
2 The ‘teacher’ questions or clarifies any facts.
3 The ‘learner’ says what they thought was done well.
4 The ‘teacher’ says what they thought was done well.
5 The ‘learner’ says what could be improved upon.
6 The ‘teacher’ says what could be improved upon.
7 Both discuss ideas for improvements in a helpful and constructive manner.

360° feedback
This collects together perceptions from a number of different participants as shown in
Figure 2.1.
The wider the spread of people giving feedback, the more rounded the picture. Each
individual gives a feedback questionnaire to at least three people in each of the groups
above. An independent person then collects and collates the questionnaires and
discusses the results with the individual. Computerised versions are available from
commercial companies.5 The main disadvantage of this method is that it can sometimes
18 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

People to whom you are responsible: managers in

your PCO or trust, clinical lead, clinical governance
lead, GPs, practice manager, patients, etc

Your peers or |___________ ^ ____________________ | Patients or

colleagues - - —1 carers
A

People responsible to you: clinical and non-clinical staff

Figure 2.1: 3 60° feedback.

be spoilt by malicious comments against which individuals cannot readily defend

themselves.

Self-assess or gain another person’s perspective on your

standard of practice or service delivery
You might describe any aspect of your practice as statements (A to G as in Box 2.2)
about your competence or performance for you to self-assess or others to give you
feedback or comments by marking the extent to which they agree on the linear scales
opposite. Objective feedback from external assessment is usually more reliable than
your own self-assessment when you may have blind spots about your own perform­
ance. As you become more confident in this method of reviewing your competence,
you might emphasise how consistent you are in your application of good practice - so
in the statements below we have sometimes included ‘consistently’, ‘always’ or
‘usually’. You can set your own challenges. If you have a mentor or a ‘buddy’ in
the practice with whom you learn, you might discuss and reflect on the completed
marking grids with him or her.
Practical ways to identify your learning and service needs 19

Box 2 .2 : Marking grid: circle the number which represents your views or
feelings about each statement - complete the grid on more than one occasion
and compare results over time
A I consistently treat patients politely and with consideration.
STRONGLY AGREE to STRONGLYDISAGREE
1------------------- 2-------------------3--------------------4 — ..................... 5-------------------6

B I am aware of how my personal beliefs could affect the care offered to the
patient, and take care not to impose my own beliefs and values.
STRONGLY AGREE to STRONGLYDISAGREE
1------------------- 2 --------- --------- 3-------------------4 --------------------- 5-------------------6

C I always treat all patients equally and ensure that some groups are not
favoured at the expense of others.
STRONGLY AGREE to STRONGLYDISAGREE
1------------------- 2-------------------3------------------- 4 --------------------- 5.........................6

D I try to maintain a relationship with the patient or family when a mistake

has occurred.
STRONGLY AGREE to STRONGLYDISAGREE
1------------------- 2 -------------------3--------------------4 --------------------- 5------------------- 6

E I always obtain informed consent to treatment.

STRONGLY AGREE to STRONGLYDISAGREE
1------------------- 2 -------------------3--------------------4 --------------------- 5....................... -6

F I usually involve patients in decisions about their care.

STRONGLY AGREE to STRONGLYDISAGREE
1------------------- 2 -------------------3— ................... 4 --------------------- 5------------------- 6

G I always respect the right of patients to refuse treatments or tests.

STRONGLY AGREE to STRONGLYDISAGREE
1------------------- 2 -------------------3--------------------4 - .....................- 5 ------------------- 6

Compare your performance against protocols or guidelines

Are you familiar with all the protocols or guidelines that are used by someone,
somewhere in your team? You might determine your learning needs and those of
other team members by piling all the protocols or guidelines that exist in your team in
a big heap and rationalising them so that you have a common set used by all. Working
as a team you can compare your own knowledge and usual practice with others and
20 DYCC in depression, dementia, alcoholism, palliative care and osteoporosis

with protocols or guidelines recommended by the National Institute for Clinical

Excellence (NICE)6 or National Service Frameworks or the Scottish Intercollegiate
Guidelines Network (SIGN).7
Alternatively, you might compare your own practice against a protocol or guideline
that is generally accepted at a national or local level. You could audit the standard of
your practice to find out how often you adhere to such a protocol or guideline, and if
you can justify why you deviate from the recommendations.

Audit
Audit is:
the method used by health professionals to assess, evaluate, and improve the care
of patients in a systematic way, to enhance their health and quality of life.8
The Five steps of the audit cycle are shown in Box 2.3.

Box 2 .3 : The five steps of the audit cycle

1 Describe the criteria and standards you are trying to achieve.
2 Measure your current performance of how well you are providing care or
services in an objective way.
3 Compare your performance against criteria and standards.
4 Identify the need for change - to performance, adjustment of criteria or
standards, resources, available data.
5 Make any required changes as necessary and re-audit later.

Performance or practice is often broken down for the purposes of audit into the three
aspects of structure, process and outcome. Structural audits might concern resources
such as equipment, premises, skills, people, etc. Process audits focus on what is done to
the patient: for instance, clinical protocols and guidelines. Audits of outcomes consider
the impact of care or services on the patient and might include patient satisfaction,
health gains and effectiveness of care or services. You might look at aspects of quality
of the structure, process and outcome of the delivery of any clinical field - focusing on
access, equity of care between different groups in the population, efficiency, economy,
effectiveness for individual patients, etc.8
Set standards for your performance, find out how you are doing, search to find out
best practice, make the changes and then re-audit the care given to patients in the
future with the same problem. Some variations on audit include:
• case note analysis. This gives an insight into your current practice. It might be a
retrospective review of a random selection of notes, or a prospective survey of
consecutive patients with the same condition as they present to see you
• peer review. Compare an area of practice with other individual professionals or
managers; or compare practice teams as a whole. An independent body might
compare all practices in one area e.g. within a PCO so that like is compared with
Practical ways to identify your learning and service needs 21

like. Feedback may be arranged to protect participants’ identities so that only the
individual person or practice knows their own identity, the rest being anonymised,
for example by giving each practice a number. Where there is mutual trust and an
open learning culture, peer review does not need to be anonymised and everyone
can learn together about making improvements in practice
• criteria-based audit. This compares clinical practice with specific standards, guide­
lines or protocols. Re-audit of changes should demonstrate improvements in the
quality of patient care
• external audit. Prescribing advisers or managers in PCOs can supply information
about indicators of performance for audit. Visits from external bodies such as the
Healthcare Commission expose the PCO or hospital trust in England and Wales to
external audit
• tracer criteria. Assessing the quality of care of a ‘tracer’ condition may be used to
represent the quality of care of other similar conditions or more complex problems.
Tracer criteria should be easily defined and measured. For instance, if you were to
audit the extent to which you reviewed the treatment of asthma, you might focus
on a drug such as beclometasone and generalise from your audit results to your
likely performance with other medications.

Significant event audit

Think of an incident where a patient or you experienced an adverse event. This might
be an unexpected death, an unplanned pregnancy, an avoidable side-effect from
prescribed medication, a violent attack on a member of staff, or an angry outburst in
public by you or a work colleague. You can review the case and reflect on the sequence
of events that led to that critical event occurring. It is likely that there were a multitude
of factors leading up to that significant event. You should take the case to a multi­
disciplinary meeting to reflect and analyse what were the triggers, causes and
consequences of the event. Complete the significant event audit cycle by planning
what individuals or the healthcare team as a whole might do to avoid a similar event
happening in future. This might include undertaking further learning and/or making
appropriate changes to your systems.
The steps of a significant event audit are shown in Box 2.4.

Box 2.4: Steps of a significant event audit

• Step 1: Describe who was involved, what time of day, what the task/activity
was, the context and any other relevant information.
• Step 2: Reflect on the effects of the event on the participants and the
professionals involved.
• Step 3: Discuss the reasons for the event or situation arising with other
colleagues, review case notes or other records.
• Step 4: Decide how you or others might have behaved differently. Describe
your options for how the procedures at work might be changed to minimise
or eliminate the chances of the event recurring.
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